Ocean Eyes Zen Center
Home
Leadership
About
Contact
Retreat Application
Gallery
Links
Calendar
F
MZO National One Day Retreat
*
Indicates required field
Name
*
First
Last
Email
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
National FMZO Retreat April 18, 2015 - 9 AM to 4 PM
*
Half Day
Whole Day
If you are taking precepts please fill in the following
Guiding Teacher
*
Ven. Dr. Wonji Dharma
Ven. Dr. Hwasahn Prajna
Ven. Dr. Sunyananda Dharma
Ven. Dr. Jishou Dharma
Ven. Haeja Prajna
Ven. Charama Bhavika Prajna
Ven. Dr. Chong'an Dharma
Ven. Do'an Dharma
Ven. Doshim Dharma
Ven. Domun Prajna
[Note: Participants may find some aspects of the retreat physically or emotionally demanding. In order to help maintain a safe environment for you and others, we ask the following questions. The following information will be kept confidential. It is requested solely in the event of an emergency.]
Do you have any known physical or mental condition that could affect your ability to participate in the retreat?
*
Yes
No
If your answer is yes, please summarize briefly, and, if applicable, provide the name of your health care practitioner who we may contact in the event of an emergency:
If Applicable
Health Care Contact
*
Please list any critical medications you take on a regular basis, and dosages:
Critical Medications
*
Please list any critical food, drug, or environmental allergies you may have:
*
RELEASE
Participants may find some aspects of the retreat program physically or mentally demanding. The program does include physical work and a vigorous daily schedule. I may freely decline to participate in any work that in my sincere judgment is dangerous to my health. I realize that I may consult with a teacher at any time to resolve any difficulties I might have. I will not leave the retreat
grounds during the program without consulting with a teacher.
I agree to release Five Mountain Zen Order and Ocean Eyes Zen Center from liability from any injury I suffer and to indemnify the same for any injury to others caused by me. By entering your full legal name you are signing this document.
How would you rate your physical health: good, fair or poor? (please select one)
*
Good
Fair
Poor
In case of accident or serious illness, whom should we notify?
*
Relative
Friend
Significant Other
Other
Relative/Other's Name
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Signature (Enter Full Legal Name)
*
Submit